Nursing Documentation

Objectives:

1. To review the importance of

documentation
2. To revisit the Do’s and Don’ts of
Charting
3. To enhance the ability to document
using focus charting
What you have written may
hurt you, but what you have
not written may hurt you
more.
Nursing Documentation

Nursing Documentation
Nursing documentation
is an important
component of nursing
practice and the
interprofessional
documentation that
occurs within the client's
health record

Nursing Documentation
Documentation — whether paper,
electronic, or audio — is used to monitor a
client’s progress and communicate with other
care providers. It also reflects the nursing
care that is provided to a client.

Nursing Documentation
 Good documentation will help you defend
yourself in a malpractice lawsuit, it can also
keep you out of court in the first place.

Nursing Documentation
Charting tips:
Documentation Do's and Don'ts

by: Eggland, Ellen Thomas, RN, MN

Nursing Documentation
 Do’s in Charting
1. Check that you have the correct chart before you
begin writing.
2. Make sure your documentation reflects the nursing
process and your professional capabilities.
3. Write legibly.
4. Chart the time you gave a medication, the
administration route, and the patient's response.

Nursing Documentation
 Do’s in Nursing Documentation
5. Do use accepted hospital abbreviation when
possible

6. Do make sure the patient’s name and ID number

appear on every page

7. Do make entries in order of the consecutive shifts

and days . Write the complete date at least once at
the beginning of your shift and at the top of every
page of notes. Indicate the time of each entry.
Nursing Documentation
Do’s in Nursing Documentation
8. Do document nursing action taken to correct
a problem, don’t just document the problem.

Example : If your patient has a leaking

catheter, you should document the bladder
palpation and balloon inflation

8. Chart patient care or procedures at the time you

provide it or as soon as possible after doing it.

Nursing Documentation
Do’s in Nursing Documentation

10.Do describe the reported symptom

accurately. Use the patient’s word if they are
helpful.

12. Record each phone call to physician,

including the exact time, message, and
response.
Do’s in Nursing Documentation
11. If you remember an important point after you've
completed your documentation, chart the
information with a notation that it's a "late
entry." Include the date and time of the late
entry.

12. Document often enough to tell the whole story.

Nursing Documentation
DON’TS in Charting
1. Don’t pull a chart by room number only..
check the name on the chart too

2. Don’t use notebook paper or a pencil .

Always use the hospital standard note form
and always use the prescribed ink color

3. Don’t chart in advance or wait until the end of

the day
Nursing Documentation
DON’TS in Charting
4. Don’t erase errors or throw nurses notes that
has error on them. If you rewrite notes, mark
the error on the original sheet and leave it in
the chart.

5. Don’t repeat in the narrative what you have

written on the other forms unless further
explanation is needed. Ex; you have written
the normal vital signs on the vital signs sheet,
don’t repeat them on the nurses notes.
Nursing Documentation
 DON’TS in Charting
6. Don’t use indefinite or vague words and terms
such as “ apparently” and “appears to be” State
your observations and substantiate them with
facts or description.

7. Don’t use medical terms unless you are sure of

their meaning

8. Don’t skip lines between entries or leave a space

between phrases or in front of your signature

Nursing Documentation
DON’TS in Charting
9. Don’tbackdate, tamper with or add to
previously written notes. Indicate the late entry
by documenting the current date and time
followed by the words late entry or addendum
and the date and the time of the occurrence

Nursing Documentation
Nursing Documentation
Nursing Documentation
 Focus charting: streamlining
documentation.

 Therefore, this system encourages

precise notation which makes the
patient’s current health status available
at a glance.
Nursing Documentation
 Advantages of Focus Disadvantages of
Charting Focus Charting

To quickly scan to find Requires reorganization

information on specific of how to chart the
concerns information

Encourages the nurse to Nurses must be able to

use the nursing process identify the focus
& to evaluate the accurately and sort the
patient’s response data into appropriate
categories.
Nursing Documentation
 Advantages of Focus Disadvantages of
Charting Focus Charting

Encourages the nurse to

identify a broader scope
of patient concerns, not
just problems

Prompts the nurse to

identify and document
the patient’s needs

Nursing Documentation
How to Use FOCUS CHARTING?

 Focus charting can help you monitor patient

problems and avoid repetitious
documentation.

Nursing Documentation
 How to Use FOCUS CHARTING?
A focus which may be written as a :

 Nursing diagnosis
 Can be a change in an acute condition
 A potential problem
 A treatment or procedure
 A conclusion about a patient’s concern or
behavior that the nurse has determined by the
systematic assessment
Nursing Documentation
Nursing Documentation
Focus charting forces you to separate focuses.

 Example:

You write 2 focus entries for a patient who

complains of both headache and
constipation
To create a focus charting:
 Note, record the date, time and focus then follow these
steps:

D- (data) document subjective &

objective data that supports the focus.

This category reflects the assessment

phase of the nursing process
To create a focus charting:
A- ( action) describe your interventions, such
as medications, treatments, call to the
physician and patient teaching.

This category reflects the planning and

implementation phases of the nursing
process.
 To create a focus charting:
R- ( response) record the patient’s
response to your interventions.

This entry always includes a new time.

You may add this line which reflects the
goal of phase of the nursing process in a
later note if necessary.
 Example of a good FOCUS note
Date Time Focus DAR ( focus notes)
June 7:30am Altera- D- Patient reports passing
9, tion in urine frequently and in
2011 comfort: small amounts, with
burning urgency & burning
upon sensation upon urination,
urination urine is cloudy & dark
amber
 Example of a good FOCUS note
Date Time Focus DAR ( focus notes)
June 7:30am Altera- A- Notified Dr. Yap.
9, tion in Urine analysis and culture
2011 comfort: specimens collected,
burning antibiotic therapy initiated.
upon Instructed patient to
urination increase fluid intake with
water & cranberry juice.
 Example of a good FOCUS note
Date Time Focus DAR ( focus notes)
June 15:50 Altera- R- Patient reports
9, tion in experiencing moderate
2011 comfort: relief from urgency and
burning burning. Fluid intake
upon increased to 480ml; lungs
urination clear. LJ Jacobs ,RN
 Focus
Date Time Progress Notes
( focus charting)
June 9, 15:30 Vomiting D: Vomited 100cc bile-colored fluid
2011 A: Gown changed. Medicated with
Compazine 10mg IM.
16:30 R: States she feels less nauseated.
No further episodes of vomiting.
Date Time Focus Progress Notes
( focus charting)
June 9, 1300 Need: D- Complaining of continuous
2011 Comfort sharp pain in mid-abdominal
or relief incisional area. Crying, “ I
of pain need something for pain now”.
States pain is 9 on a scale of 10

A- A- Medicated with
Demerol 75mg IM in LUOQ of
left buttock. Repositioned on
right side with pillow to
abdomen to help splint wound
Date Time Focus Progress Notes
( focus charting)
June 9, 14:05 Need: R- Patient stated pain was
2011 Comfort “much better” 30 minutes later
or relief and rated it 3 on a scale of
of pain 10_____________N. Nurse, RN
 Criteria for a Complete Documentation

1.The patient’s chart will be legally sound

2. Reflects the nursing process ( A, P, I, E)
3. Provide a current, complete, concise description of
the patient’s status with the least possible
duplication of information
4. Will record all nursing objectives, treatment and
the health assessment.

Nursing Documentation
 II Timothy 2:15
Do your best to present yourself
to God as one approved, a
workman who does not need to
be ashamed and who correctly
handles the word of truth.
References :
Iyer, Patricia. Nursing Malpracticehttp://booksgoogle.com.ph/books

http://journals.lww.com/nursing/citation/1993/08000/charting_tips__documentation_do_s_and_dont_s
.16.aspx

http://www.cno.org/Global/docs/prac/41001_documentation.pdf

http://journals.lww.com/nursing/Citation/2000/30050/How_to_use_Focus_charting.44.aspx